Functional improvement after inpatient rehabilitation in community hospitals following acute hospital care.

INTRODUCTION: There are limited studies exploring functional improvement in relation to characteristics of patients who, following acute hospital care, receive inpatient rehabilitation in community hospitals. We evaluated the association of acute hospital admission-related factors with functional improvement on community hospital discharge. METHODS: We conducted a retrospective cohort study among patients who were transferred to community hospitals within 14-day post-discharge from acute hospital between 2016 and 2018. Modified Barthel Index (MBI) on a 100-point ordinal scale was used to assess functional status on admission to and discharge from the community hospital. We categorised MBI into 6 bands: 0-24, 25-49, 50-74, 75-90, 91-99 and 100. Multivariable logistic regression models were constructed to determine factors associated with categorical improvement in functional status, defined as an increase in at least one MBI band between admission and discharge. RESULTS: A total of 5,641 patients (median age 77 years, interquartile range 69-84; 44.2% men) were included for analysis. After adjusting for potential confounders, factors associated with functional improvement were younger age, a higher MBI on admission, and musculoskeletal diagnosis for the acute hospital admission episode. In contrast, a history of dementia or stroke; lower estimated glomerular filtration rate; abnormal serum albumin or anaemia measured during the acute hospital episode; and diagnoses of stroke, cardiac disease, malignancy, falls or pneumonia; and other chronic respiratory diseases were associated with lower odds of functional improvement. CONCLUSION: Clinicians may want to take into account the presence of these high-risk factors in their patients when planning rehabilitation programmes, in order to maximise the likelihood of functional improvement.

Hospital Pharmacists and Antimicrobial Stewardship: A Qualitative Analysis.

Antimicrobial stewardship programmes (ASPs) in hospitals are predominantly led by specific ASP physicians and pharmacists. Limited studies have been conducted to appreciate non-ASP-trained hospital pharmacists' perspectives on their roles in antimicrobial stewardship. Focus group discussions (FGDs) were conducted with 74 pharmacists, purposively sampled from the 3 largest acute-care public hospitals in Singapore, to explore facilitators and barriers faced by them in antimicrobial stewardship. Applied thematic analysis was conducted and codes were categorised using the social-ecological model (SEM). At the intrapersonal level, pharmacists identified themselves as reviewers for drug safety before dispensing, confining to a restricted advisory role due to lack of clinical knowledge, experience, and empowerment to contribute actively to physicians' prescribing decisions. At the interpersonal level, pharmacists expressed difficulties conveying their opinions and recommendations on antibiotic therapy to physicians despite frequent communications, but they assumed critical roles as educators for patients and their caregivers on proper antibiotic use. At the organisational level, in-house antibiotic guidelines supported pharmacists' antibiotic interventions and recommendations. At the community level, pharmacists were motivated to improve low public awareness and knowledge on antibiotic use and antimicrobial resistance. These findings provide important insights into the gaps to be addressed in order to harness the untapped potential of hospital pharmacists and fully engage them in antimicrobial stewardship.

Sustainable implementation of advance care planning in Asia: An interpretive-systemic framework for national development.

OBJECTIVES: A qualitative interpretive-systemic focus group study was conducted to examine the developmental and implementational underpinnings of Asia's first national Advance Care Planning (ACP) programme constituted in Singapore. METHODS: 63 physicians, nurses, medical social workers, and allied health workers who actively rendered ACP were purposively recruited across seven major public hospitals and specialist centers. RESULTS: Framework analysis revealed 19 themes, organized into 5 categories including Life and Death Culture, ACP Coordination, ACP Administration, ACP Outcomes, and Sustainability Shift. These categories and themes formed an Interpretive-Systemic Framework of Sustainable ACP, which reflects the socio-cultural, socio-political, and socio-spiritual contexts that influence ACP provision, highlighting the need to adopt a public health strategy for enhancing societal readiness for end-of-life conversations. SIGNIFICANCE OF RESULTS: The Interpretive-Systemic Framework of Sustainable ACP underscores the importance of health policy, organizational structure, social discourse, and shared meaning in ACP planning and delivery so as to support and empower care decision-making among terminally ill Asian patients and their families facing mortality.

The development and validation of a prototype mobility tracker for assessing the life space mobility and activity participation of older adults.

BACKGROUND: There is increasing interest in examining the life space mobility and activity participation of older adults in the community using sensor technology. Objective data from these technologies may overcome the limitations of self-reported surveys especially in older adults with age-associated cognitive impairment. This paper describes the development and validation of a prototype hybrid mobility tracker for assessing life space mobility and out-of-home activities amongst 33 community-ambulant older adults in Singapore. METHODS: A hybrid mobility tracker was developed by combining a passive Global Positioning System logger, tri-axial accelerometer and radio-frequency identification. Objective measures of life space, derived from 1 week of tracking data using Geographic Information Systems, were the maximum Euclidean distance from home (Max Euclid) and the area of the minimum convex polygon surrounding all GPS waypoints (MCP area). Out-of-home activities were quantified by visually identifying the total number of activity nodes, or places where participants spent ≥5 min, from mobility tracks. Self-reported measure of life space in 4 weeks was obtained using the University of Alabama at Birmingham Study of Life Space Assessment (UAB-LSA) questionnaire. Self-reported out-of-home activities were recorded daily in a travel diary for 1 week. Bivariate correlations were used to examine convergent validity between objective and subjective measures of life space and out-of-home activities. RESULTS: The mean age of participants was 69.2 ± 7.1 years. The mean UAB-LSA total score was 79.1 ± 17.4. The median (range) Max Euclid was 2.44 km (0.26-7.50) per day, and the median (range) MCP area was 3.31 km2 (0.03-34.23) per day. The UAB-LSA total score had good correlation with Max Euclid (r = 0.51, p = 0.002), and moderate correlation with MCP area (r = 0.46, p = 0.007). The median (range) total number of activity nodes measured by tracker of 20 (8-47) per week had a good correlation with the total activity count recorded in the travel diaries of 15 (6-40) per week (r = 0.52, p = 0.002). CONCLUSIONS: The tracking system developed to understand out-of-home travel was feasible and reliable. Comparisons with the UAB-LSA and travel diaries showed that it provided reliable and valid spatiotemporal data to assess the life space mobility and activity participation of older adults.